Provider Demographics
NPI:1578780714
Name:WICKHAM, MARIA D (RPT)
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:D
Last Name:WICKHAM
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2588 HYLER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-2949
Mailing Address - Country:US
Mailing Address - Phone:323-257-5736
Mailing Address - Fax:
Practice Address - Street 1:3699 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2719
Practice Address - Country:US
Practice Address - Phone:323-783-7499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17945225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist